Healthcare Provider Details

I. General information

NPI: 1467755611
Provider Name (Legal Business Name): SARAH RENEE STARK M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 ANN ARBOR RD
JACKSON MI
49201-8801
US

IV. Provider business mailing address

3317 PINE CREEK DR
BRIGHTON MI
48114-8663
US

V. Phone/Fax

Practice location:
  • Phone: 517-879-1505
  • Fax:
Mailing address:
  • Phone: 248-974-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: